INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Bucks County Counseling was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill records, the facility failed to ensure that the unannounced fire drills were conducted during different times of the day.
The findings include:
The fire drill records were reviewed on August 4, 2015. The timeframe reviewed was August 2014 through July 2015. The facility's normal business hours of operation are from 9:00 a.m. until 5:00 p.m., as well as group sessions on Mondays, Wednesdays, and Thursdays from 6:00 p.m. to 8:00 p.m. All of the drills were conducted and documented after 4:00 p.m. The facility failed to document fire drills between the hours of 9:00 a.m. and 4:00 p.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director has created schedule in computer program that will alert director to fire drill on different times of month and different times of day between 9:00am and 8:00pm. |